New Polling: Patients and Providers Oppose Prior Authorization Policies Imposed by Insurers and PBMs

Overwhelming Majority of Consumers Support Reforms to Improve Access and Affordability

A recent national poll commissioned by Let My Doctors Decide (LMDD) found that a majority of health care consumers oppose prior authorization policies imposed by health insurance companies and pharmacy benefit managers (PBMs), which often result in access restrictions, increased patient costs, and delayed health and wellness.

Prior authorization is a harmful utilization management practice that requires doctors to obtain specific approval from health insurers before they are able to prescribe a treatment to their patients. This time-consuming process not only requires health care providers to take valuable time away from patients, but it can also lead to negative health outcomes.

The nationwide poll, conducted by Lake Research Partners and the Tarrance Group found that:

• 75% of health care consumers are concerned that prior authorization can delay or block patients' access to treatment.
• 71% are worried that prior authorization will increase patient costs.
• 74% expressed concern that prior authorization can require patients to substitute less effective or ineffective treatments for what their doctors prescribed.
• 72% said they are concerned that such policies can override doctors' recommendations by allowing insurance companies to control treatment decisions.

"Our bipartisan survey reveals widespread and serious concerns among health care consumers about the impact of prior authorization on the quality of their care," said David Mermin, Lake Research Partners. "Patients clearly want access to the treatments their doctors recommend without delays or interference by insurance companies."

Quardricos Driskell, Executive Director of LMDD and Vice President of Public Policy and Government Affairs at the Autoimmune Association, emphasized the serious impact on patients. "Prior authorization, step therapy and other harmful barriers further complicate health issues and defer wellness for more than 50 million patients who are dealing with existing complications because of their immune-mediated diseases," according to Driskell. "It's time to level the playing field for patients with meaningful reforms that will break down insurance company and PBM barriers to ensure increased access to much-needed medicines and treatments."

Providers Share Details About Negative Impact of Prior Authorization

Related research conducted by Xcenda of rheumatology providers in several states found significant delays in the vast majority of prior authorization decisions requests as a result of insurance company and PBM requirements.

• 90% of providers said prior authorization decisions were delayed sometimes or most of the time.
• Nearly 50% of cases are denied by insurance companies and must go through an appeal process.
• In the majority of requests, payers require proof that the patient has failed on a medicine or treatment before the payer will consider the request.

This harmful "fail first" practice is known as step therapy, which requires a patient to fail on a drug or treatment before the insurance company will agree to cover the original doctor-recommended medicine, further delaying health and wellness and putting at risk the critical doctor-patient relationship.

"Xcenda's survey research of rheumatology providers demonstrates that prior authorization and fail first practices remain a significant barrier for providing care to patients," said Paula Hilton, MHA/Director of Value Access and Strategy at Xcenda. "Addressing the administrative burden of prior authorization requests would increase the time providers spend treating patients."

Polling results indicate that patients are concerned about prior authorization burdens on providers and office staff, and payer procedures in rheumatology offices create the biggest challenges.

• 71% of polling respondents are worried that filing and following up on prior authorization requests diverts doctor and staff time spent with patients.
• 60% of rheumatologists said they are directly responsible for prior authorization requests.
• Half of office staff in rheumatology offices said they are also responsible for prior authorization requests.
• Benefit specialists in rheumatology offices work with more than 10 health insurance companies, each with separate requirements, complicated paperwork, and often requiring considerable phone time.
• Technology requirements that plague patients and providers are often roadblocks, with 8 of out 10 offices still relying on fax machines, a dated technology that often poses delays and frustrations for patients and providers.

The need to streamline and automate prior authorization procedures are common themes in both the polling and research.

Both the national polling data and the rheumatology-specific research found a majority of respondents believe that prior authorization reform should be a priority for federal and state policymakers. Sixty-four percent of polling respondents believe it should be a priority, with 27% saying it should be a top priority. Similar sentiment was found in the research from rheumatology offices, with most offices suggesting a variety of changes to streamline the prior authorization process.

"This bipartisan poll finds health care consumers frustrated with the burdens of prior authorization, with the majority agreeing that patients should not be subject to such requirements," said Brian Nienaber, Tarrance Group.

The polling and rheumatology-specific research support findings of the recent LMDD national health insurance scorecard which found that three out of four insurance plans received a "C" or "F" because of prior authorization, step therapy, and other access restrictions placed on patients.

LMDD 2023 Principles Patient Principles and Call to Action are designed to provide meaningful reforms and strongly encourage the adoption of straightforward principles that address the barriers that prevent patients and doctors from making treatment decisions. This includes changes needed at national and state levels to improve benefit design, promote access and equality, and ensure coverage that empowers provider decision making, promotes access and adherence, and addresses affordability.

To view the complete results, click here.

About Let My Doctors Decide

Let My Doctors Decide is a national partnership – convened by the Autoimmune Association in 2017 – of leaders across health care working in support of a simple goal: treatment decisions should always be made by patients and trusted health care professionals, not insurance companies or pharmacy benefit managers. Founded in 2017, Let My Doctors Decide (LMDD) brings together patients, providers, and advocates – especially those from the autoimmune disease community – to raise awareness about affordability and access issues.

About the Autoimmune Association

For over 30 years, the Autoimmune Association has been a pioneer in serving autoimmune patients, sponsoring research, advocating for access to health care, and fostering collaboration to identify and explore the common threads that link autoimmune diseases. Established through the remarkable determination of Founder Virginia T. Ladd, the Autoimmune Association has transformed into an internationally recognized leader, reaching over 60 countries worldwide. To mark its 30-year legacy and global impact on the autoimmune community, the name of the organization was changed from its original name, the American Autoimmune Related Diseases Association (AARDA).

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